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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 06/16/2023
Date Signed: 06/16/2023 03:48:44 PM

Document Has Been Signed on 06/16/2023 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AEGIS ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347003994
ADMINISTRATOR:DONALD STAMETSFACILITY TYPE:
740
ADDRESS:4050 WALNUT AVETELEPHONE:
(916) 972-1313
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 90CENSUS: 67DATE:
06/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Tracy LehnerTIME COMPLETED:
04:00 PM
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On 6/16/23, Licensing Program Analyst (LPA) Kevin Mknelly, met with the Director to follow-up on a recent incident and report regarding R1.

R1 is a resident in memory care that continues to, at times, have aggressive intentions.

LPA and the Director discussed current and ongoing strategies and interventions which may be most effective for caregivers working with R1. The licensee is also exploring options, with R1's responsible parties, for other communities which may meet R1's needs.

LPA and the Director observed and met with R1 in his community. R1 was engaging and not demonstrating overt behaviors during the time of the visit.

As a result of today’s inspection, no deficiencies were found at this time.
Report was reviewed with the Director and copy provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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